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A 10% late fee will be added to any invoice where payment has not been received within 30 days of receipt.
Therapy services may be put on hold or terminated if there is a problem regarding payment. There is a $39 service fee for all returned checks. Please do not hesitate to contact us regarding questions of billing/payments. We are willing to work with each client to ensure a balance between providing therapy services and addressing business issues or concerns.
I authorize Beyond Limits Audiology to bill my insurance company for direct reimbursement of therapy services rendered to my child and authorize release of any medical information necessary to process the claim. I assign benefits for filed claims to be paid to Beyond Limits Audiology and will turn over any payments sent directly to me by my insurance provider that were intended to cover services provided by Beyond Limits Audiology. I understand that I am responsible for payment of any services not paid or not paid in full by insurance.
By signing this document, I certify that I have read and understand its contents and that information provided by me is accurate and complete (including insurance information and current eligibility for benefits)
Beyond Limits Audiology will now contact patients for appointment reminders using text messages and email messages through our HIPAA compliant electronic medical records system (EMR). In these notifications, you will have the option to confirm or cancel. Please do so immediately upon receipt. If you need to reschedule your appointment, please call the office at 770-917-5737.
Beyond Limits Pediatric Therapy Center ATTENDANCE POLICY
Your child’s progress in therapy is a direct result of regular attendance to his/her therapy sessions, open communication with your child’s therapist(s) and office staff, and compliance with your child’s home exercise program as instructed by his/her therapist(s). BLPTC institutes an attendance policy to monitor and ensure that patients regularly attend their scheduled appointments for an overall successful therapy program. For this reason, in addition to many increasingly strict attendance-related insurance requirements and a growing community need for services, Beyond Limits Pediatric Therapy Center is committed to upholding the following attendance policy. We require a 24-Hour notice for cancellations. We reserve a time specifically for your child; because of our lengthy waitlists, some children rely on cancellations in order to be seen for therapy. A twenty-four hour notice gives our office ample time to notify patients who currently can only be seen on a call-in basis. We know that sickness occurs. Therefore, if you think that your child is sick the night before their appointment, or wakes up sick, please call/text us and give us notice so that we can plan accordingly. The following signs may indicate a communicable disease/illness: vomiting, fever, diarrhea, sore throat, rash/swelling and red/running eyes. In the event of a cancellation, it is the patient’s responsibility to reschedule any missed appointment. BLPTC reserves the right to transition any patient to a flex schedule, which entails scheduling on a week-to-week basis rather than maintaining an established recurring appointment for any of the following reasons: • Three canceled appointments for any reason (including those with greater than a 24-hour notice), • Two no-shows (missed appointments without a telephone call to cancel OR cancellations with less than a 24-hour notice), or • Erratic and/or inconsistent attendance (including, but not limited to, arriving late for appointments OR routinely cancelling appointments non-consecutively). All of the above may adversely affect your child’s progress in meeting the goals set forth in his/her plan of care. In the event of any of the above reasons, therapy patients may be discharged or transitioned to a flex schedule. The patient’s physician and insurance carrier will be notified. Missed/canceled visits or other unusual attendance problems are also documented in the patient’s medical record. If your child is discharged because of attendance problems, any re-admission to BLPTC will require approval by the treating therapist and office manager (and a new physician’s therapy prescription is required). A minimum of a twenty-four (24) hour notice must be given for any cancellation or to reschedule appointments. Cancellations with less than a 24-hour notice will be deemed a no-show. Patients must be on time for their scheduled appointment. If your child is 10 minutes or more late, he/she may not be able to be seen at that time and could have to wait until his/her next scheduled appointment. In the case of a provider’s absence, if an opening is available for a patient to be treated at the same time with an alternate provider, the appointment will be moved to another provider’s schedule to ensure care may be provided. Please note if BLPTC needs to cancel an appointment (ex: closure/holidays, therapist is out of office, plan of care is pending doctor signature, or insurance authorization is pending), this will not count against your attendance record. We will do our best to reschedule your child’s therapy session(s).
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about your child. We understand that his or her medical information is personal to you and we are committed to protecting that information. As our client, we create medical records about your child's health, our care for him/her, and the services we provide for your child. By law, we are required to make sure that your child's protected health information is kept private. Beyond Limits Audiology is a teaching facility that allows students to observe our therapists and/or participate in the treatment of patients for school requirements. No information will be shared outside of the therapy session.
By signing this form, you consent to our use and disclosure of protected health information about your child for treatment, payment, and healthcare operations. This practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You also acknowledge that the Beyond Limits Audiology Privacy Notice (Revision Date, October 1, 2018) has been made available to you. This Notice is also displayed in our office and on the Beyond Limits Audiology website www.beyondlimitstherapy.org. If you are completing these forms online, please click here to see our Notice of Privacy Policies. A paper copy of this Notice will be provided any time it is requested.
Beyond Limits Audiology likes to use pictures/videos of students/clients/therapists/staff on our website, social media, brochures, invitations, slideshows, educational, and other programs. This form allows or prohibits Beyond Limits Audiology to use your child’s picture or videotape for marketing, educational or other purposes. Please select an option and initial next to your selection.
I understand that the information authorized shall not be released beyond the mediums indicated and that any other uses other than those listed above shall be communicated with me beforehand. I also understand that the parties hereby authorized shall not be responsible for any unauthorized uses that may result by any person copying or hacking the previously identified mediums without proper authorization.
I further understand that this consent may be revoked by me at any time by submitting a written revocation notice. I understand that this authorization will remain in effect until such time that I rescind my consent via written notification.
If you are a foster parent bringing a foster child to therapy, please select ‘No’.
I, (parent/guardian), knowing that (child’s name) has a diagnosis that may benefit from physical, speech, or occupational therapy treatment, voluntarily consent to such care for the aforementioned child by the therapist doing business for Beyond Limits Audiology as may be beneficial in the professional judgment of my child’s therapist. I consent to care and treatment that falls within the scope of practice as defined by the State of Georgia for each discipline.
I understand that treatment will involve physical participation on the part of the patient, which may involve risks of injury. I acknowledge that I am responsible for making my therapist(s) aware of any changes in my child’s physical or mental status. I release Beyond Limits Audiology, its therapists, students, staff and independent contractors from any liability for any accident or injury that is not directly caused by negligence.
Beyond Limits Audiology may utilize independent contractors for evaluations and therapy sessions. These include, but are not limited to, speech therapists, occupational therapists, physical therapists, and consulting and referring physicians. Healthcare professionals that are independent contractors are not agents or employees of Beyond Limits Audiology and are responsible for their own actions. I understand that Beyond Limits Audiology shall not be liable for the acts or omissions of independent contractors. This Consent to Treatment also applies to any independent contractor utilized by Beyond Limits Audiology.
I authorize Beyond Limits Audiology to release or communicate necessary and pertinent information to physicians, case managers, and insurance companies for my child . Approved information may be given to, received from, and discussed with the following people directly related to my child's care. Approved information includes all written documentation and evaluations and/or verbal discussions.